1. ADVICE

2. Advice Strongly advise adherence to diet and medication Smoking cessation, exercise, weight reduction Ensure diabetes education and advise Diabetes UK membership Stress role of the whole Diabetes Care Team Regular follow-up with comprehensive Annual Review is essential. 20% of patients with early severe complications will be persistent non-attenders Lifestyle targets: weight reduction >5% if obese, fat intake 15g per 1000 calories, exercise for four hours / week.

3. Obesity Trends Among U.S. Adults 1985

4. Obesity Trends Among U.S. Adults 1986

5. Obesity Trends Among U.S. Adults 1987

6. Obesity Trends Among U.S. Adults 1988

7. Obesity Trends Among U.S. Adults 1989

8. Obesity Trends Among U.S. Adults 1990

9. Obesity Trends Among U.S. Adults 1991

10. Obesity Trends Among U.S. Adults 1992

11. Obesity Trends Among U.S. Adults 1993

12. Obesity Trends Among U.S. Adults 1994

13. Obesity Trends Among U.S. Adults 1995

14. Obesity Trends Among U.S. Adults 1996

15. Obesity Trends Among U.S. Adults 1997

16. Obesity Trends Among U.S. Adults 1998

17. Obesity Trends Among U.S. Adults 1999

18. Obesity Trends Among U.S. Adults 2000

19. Obesity Trends Among U.S. Adults 2001

20. Obesity Trends Among U.S. Adults 2002

21. Obesity Trends Among U.S. Adults 2003

22. Obesity Trends Among U.S. Adults 2004

23. Sedentary lifestyle/ physical inactivity High fat, energy dense diet Ethnicity Family history Stopping smoking Age Risk factors for obesity

24. Health risks of obesity Risk x >3 International Obesity Task Force Risk x 2-3 Risk x 1-2

25. Cancer Gall- bladder disease Kidney failure Stroke Heart failure Athero- sclerosis Type 2 diabetes Hyper- tension Respiratory disease Obesity The health consequences of obesity

26. 5 1.0 1.5 4.4 6.7 11.6 21.3 42.1 2.2 2.9 4.3 5.0 15.8 27.6 40.3 54.0 93.2 8.1 10 Women Men 40 70 100 0 <22<2323- 23.9 Body mass index (kg/m 2 ) 24.926.928.930.932.934.9 24-25-27-29-31-33-35+ Risk of type 2 diabetes The relationship between BMI and the risk of developing type 2 diabetes

27. Health benefits of 10 kg weight loss in 100 kg subject Death:20-25% decrease in premature mortality Diabetes:50% decrease in risk of Type 2 DM 30-50% decrease in blood glucose Lipids:10% decrease in total cholesterol 30% decrease in triglycerides Blood 10mmHg decrease in systolic pressure:20mmHg decrease in diastolic

28. How will you encourage patients to achieve weight loss? ?

29. BMI DOES NOT –show the difference between excess fat and muscle. –identify whether the fat is laid down in particular sites. For example, abdominal fat has more serious health consequences than fat located elsewhere. The relation between fatness and BMI differs with age, race and gender.. Measuring obesity up to here The limitations of the Body Mass Index

30. BMI = weight (kg)/height (m²) Individuals with a BMI –between 25 to 29.9 are considered overweight –of 30 and above are considered obese. The risk of serious health consequences such as type 2 diabetes, coronary heart disease, hypertension, dyslipidaemia, albuminuria and a wide range of other conditions increases with BMI. Obesity is most commonly assessed by a single measure, the Body Mass Index (BMI), which uses a mathematical formula based on a person’s height and weight. Measuring obesity Body Mass Index

31. The presence of abdominal obesity is more highly correlated with the metabolic risk factors than is an elevated BMI. The new IDF consensus definition of the metabolic syndrome stipulates the following as a pre-requisite for a diagnosis of metabolic syndrome: ≥ 80 cm for European women ≥ 94 cm for European men Waist circumference is calculated by comfortably measuring the waist halfway between the bottom of the rib cage and the top of the pelvis. Waist circumference and the metabolic syndrome

32. Central Obesity Waist circumference - ethnicity specific* - for Europids: Male ≥ 94 cm Female ≥ 80 cm plus any two of the following: Raised Triglycerides ≥150mg/dL (1.7mmol/L) or specific treatment for this lipid abnormality Low HDL Cholesterol <40mg/dL (1.03 mmol/L) in males <50mg/dL (1.29 mmol/L) in females or specific treatment for this lipid abnormality Raised blood pressure Systolic : ≥130 mmHgor Diastolic: ≥85 mmHgor Treatment of previously diagnosed hypertension Impaired fasting glycaemia Fasting plasma glucose ≥100 mg/dL (5.6 mmol/L) or previously diagnosed type 2 diabetes If above 5.6 mmol/L or 100 mg/dL, OGTT is strongly recommended but is not necessary to define presence of the syndrome. Metabolic syndrome: IDF consensus definition (2005)

33. Physical activity and risk of stroke British Regional Heart Study Wannamethee & Shaper (1992) BMJ; 304: 597-601 0 1 2 3 4 Age-adjusted stroke rate Inact Occas Light Mod Mod-Vig Vig

34. Progression of IGT to Diabetes The Finnish Diabetes Prevention Study and the Diabetes Prevention Program (DPP) both showed that lifestyle changes can reduce progression to diabetes in patients with impaired glucose tolerance (IGT). The results of the two studies were surprisingly concordant.

35. Lifestyle changes reducing progression to diabetes mellitus Diabetes Prevention ProgramFinnish Diabetes Prevention Study 7% weight loss in the obese> 5% weight loss Avoid excess alcoholFat intake < 30% of total calories Diet adviceSaturated fat < 10% of total calories Smoking adviceFibre intake ≥ 15g per 1000 calories intake 150 mins of moderate exercise per week (mainly walking or cycling) Exercise > 4 hours per week Other dietary measures: increased vegetables and fruits, decreased sugar, decreased salt Lifestyle changes reducing progression to diabetes mellitus

36. Progression of IGT to Diabetes There was decreased progression from IGT to diabetes of 58% with lifestyle changes in both studies over a three year period. The metformin limb of the DPP showed that metformin 850mg twice daily reduced progression from IGT to diabetes by 31%.

37. 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 123456 Success score Incidence of Diabetes during FU Intervention group Control group Diabetes Prevention Success Follow up 2-3 years n= 522, overweight 16T Intervention group 27 cases, 10% Control group 59 cases, 22%, reduction of 58% Metformin 850mg bb reduction of 31% only

38. Why the decline in Coronary Death rates? N = 68200 in 2001 versus 1980 ? B Unal, J Critchley,S Capewell, BMJ. 2005 Sep 17;331(7517):614

39. BP Other Smoking Statin Low chol Dietary changes N = 68200 smoking29715 Other22860 BP5870 Popn Chol5770 Statin2135 Why the decline in Coronary Death rates? B Unal, J Critchley,S Capewell, BMJ. 2005 Sep 17;331(7517):614.

41. Advice Strongly advise adherence to diet and medication Smoking cessation, exercise, weight reduction Ensure diabetes education and advise Diabetes UK membership Stress role of the whole Diabetes Care Team Regular follow-up with comprehensive Annual Review is essential. 20% of patients with early severe complications will be persistent non-attenders Lifestyle targets: weight reduction >5% if obese, fat intake 15g per 1000 calories, exercise for four hours / week.